Acquired ptosis:

Aetna considers any of the following procedures medically necessary when the criteria described below are met:

1. Blepharoplasty* is considered medically necessary for any of the following indications:

   1. To correct prosthesis difficulties in an anophthalmia socket; or 
   2. To remove excess tissue of the upper eyelid causing functional visual impairment when photographs in straight gaze show eyelid tissue resting on or pushing down on the eye lashes (Note: Excess tissue beneath the eye rarely obstructs vision, so the lower lid blepharoplasty is rarely covered for this indication); or 
   3. To repair defects predisposing to corneal or conjunctival irritation:
       
      
      • Corneal exposure
      • Ectropion (eyelid turned outward)
      • Entropion (eyelid turned inward)
      • Pseudotrichiasis (inward misdirection of eyelashes caused by entropion); or
         
   4. To relieve painful symptoms of blepharospasm; or 
   5. To treat peri-orbital sequelae of thyroid disease and nerve palsy, and peri-orbital sequelae of other nerve palsy (e.g., the oculomotor nerve).
       
2. Ptosis (blepharoptosis) repair for laxity of the muscles of the upper eyelid causing functional visual impairment when photographs in straight gaze show the margin reflex difference (distance from the upper lid margin to the midpoint of the pupil) of 2 mm or less. 
    
3. Brow ptosis repair for laxity of the forehead muscles causing functional visual impairment when photographs show the eyebrow below the supra-orbital rim.
    
4. Eyelid ectropion or entropion repair is considered medically necessary for corneal or conjunctival injury due to ectropion, entropion or trichiasis.
    
5. Upper eyelid tightening procedures (block resection or tarsal strip with lateral canthal tightening) for member who has refractory corneal or conjunctival inflammation related to exposure from floppy eyelid syndrome.

* Canthoplasty is considered medically necessary as part of a blepharoplasty procedure to correct eyelids that sag so much that they pull down the upper eyelid so that vision is obstructed.

Note: Visual field testing is not routinely necessary to determine the presence of excess upper eyelid skin, upper eyelid ptosis, or brow ptosis.  Each of these 3 components can be present alone or in any combination, and each may require correction.  If both a blepharoplasty and ptosis repair are requested, 2 photographs may be necessary to demonstrate the need for both procedures: 1 photograph should show the excess skin above the eye resting on the eyelashes, and a 2nd photograph should show persistence of lid lag, with the upper eyelid crossing or slightly above the pupil margin, despite lifting the excess skin above the eye off of the eyelids with tape.  If all 3 procedures (i.e., blepharoplasty, blepharoptosis repair, and brow ptosis repair) are requested, 3 photographs may be necessary.

Congenital ptosis:

Aetna considers surgical correction of congenital ptosis medically necessary to allow proper visual development and prevent amblyopia in infants and children with moderate to severe ptosis interfering with vision.  Surgery is considered cosmetic if performed for mild ptosis that is only of cosmetic concern.  Photographs must be available for review to document that the skin or upper eyelid margin obstructs a portion of the pupil.

See also CPB 0031 - Cosmetic Surgery.

Blepharoplasty refers to surgery to remove excess skin and fatty tissue around the eyes.  Blepharochalasis is a term used to refer to loose or baggy skin (dermatochalasis) above the eyes, so that a fold of skin hangs down, often concealing the tarsal margin when the eye is open.  In severe cases, excess skin and fat above the eyes can sit on the upper eyelid and may obstruct the superior field of vision.  Blepharochalasis may cause pseudoptosis (false ptosis), where the patient has a normal ability to elevate the eyelid, but bagging skin above the eye overhangs the eyelid margin, resembling ptosis.  In some cases, excess skin around the eye may cause the eyelashes to turn in and to irritate the eye, or turn outward, resulting in exposure keratitis.

Surgical removal of these overhanging skin folds may improve the function of the upper eyelid and restore peripheral vision.  Blepharoplasty is also performed for cosmetic reasons to improve a sagging, tired appearance, and is the second most common aesthetic procedure performed by plastic surgeons.  For coverage of this procedure, photographs in straight gaze should show sagging tissue above the eyes that is resting on or pushing down on the eyelashes.

Blepharoplasty to remove excess tissue either above or below the eyes may also be medically necessary and covered to correct prosthesis difficulties in an anophthalmia socket, to repair defects caused by trauma or tumor-ablative surgery, to correct an entropion (inward turned eyelid) or ectropion (outward turned eyelid), to treat peri-orbital sequelae of thyroid disease and nerve palsy, and to relieve painful blepharospasm.

Ptosis (also called blepharoptosis) is the term for drooping of one or both upper eyelids.  This may occur in varying degrees from slight drooping to complete closure of the involved eyelid.  In the most severe cases, the drooping can obstruct the visual field and cause positional head changes.

There are 2 types of ptosis: (i) acquired and (ii) congenital.  Acquired ptosis is more common.  Congenital ptosis is present at birth.  Ptosis may occur because the levator muscle's attachment to the lid is weakening with age.  Acquired ptosis can also be caused by a number of different things, such as disease that impairs the nerves, diabetes, injury, tumors, inflammation, or aneurysms.  Congenital ptosis may be caused by a problem with nerve innervation or a weak muscle.  Drooping eyelids may also be the result of diseases such as myotonic dystrophy or myasthenia gravis.

The primary symptom of ptosis is a drooping eyelid.  Adults will notice a loss of visual field because the upper portion of the eye is covered.  Children who are born with a ptosis usually tilt their head back in an effort to see under the obstruction.  Some people raise their eyebrows in order to lift the lid slightly and therefore may appear to be frowning.

Diagnosis of ptosis is usually made by observing the drooping eyelid.  Ptosis is usually treated surgically.  Surgery can generally be done on an outpatient basis under local anesthetic.  For minor drooping, a small amount of the eyelid tissue can be removed.  For more pronounced ptosis the approach is to surgically shorten the levator muscle or connect the lid to the muscles of the eyebrow.  Or, the aponeurosis can be re-attached to the tarsal plate if it had separated.  Correcting the ptosis is usually done only after determining the cause of the condition.

Ptosis (blepharoptosis) repair for laxity of the muscles of the upper eyelid causing functional visual impairment is covered when photographs in straight gaze show the eyelid margin across the midline or at the most 1 or 2 mm above the midline of the pupil (see Figure).

Figure: Diagram of upper lid margin crossing the pupil

To demonstrate the medical necessity of both blepharoplasty and ptosis (blepharoptosis) repair, 2 photographs may be needed.  One photograph should demonstrate the excess skin above the eyes resting on the eyelashes.  A second photograph should be taken with the excess skin lifted off of the eyelashes (such as by taping the excess skin to the forehead), and demonstrating persistence of ptosis with the lid margin across the midline of the pupil or 1 to 2 mm above the pupil midline.

Brow ptosis refers to sagging tissue of the eyebrows and/or forehead.  In extreme cases, brow ptosis can obstruct the field of vision.  Brow ptosis is caused by aging changes in the forehead muscle and skin, which leads to weakening of these tissues and sagging of the eyebrows.  Brow ptosis is treated surgically with the specific operation being based on the amount and location of the brow ptosis.

Brow ptosis surgery is usually performed under local anesthesia as an outpatient procedure.  Excess skin and muscle is excised and the deep tissues are sutured together.  Brow ptosis repair for laxity of the forehead muscles causing functional visual impairment is covered when photographs show the eyebrow below the supra-orbital rim.

Often brow ptosis coexists with eyelid ptosis and dermatochalasis; in these cases, ptosis surgery and blepharoplasty may be performed at the time of the brow ptosis surgery.  The medical necessity of each surgical procedure may need to be demonstrated with separate photographs: 1 photograph should show the eyebrow below the supra-orbital rim, a 2nd photograph with the sagging forehead lifted up in order to see the sagging tissue above the eye resting on the eyelashes, and then a 3rd with the sagging tissue lifted off of the eyelid in order to see the persistent lid lag (ptosis).

Canthoplasty, also known as inferior retinacular suspension or lateral retinacular suspension, involves tightening the muscles or ligaments that provide support to the outer corner of the eyelid.  This procedure may be medically necessary where drooping of the outer corner of the eyelid interferes with vision. 

Visual field testing is not necessary to determine the presence of excess upper eyelid skin, upper eyelid ptosis, or brow ptosis.  A patient could cause a visual field defect by lowering their lids during the test.  Photographs that document eyelids crossing the pupils provide a practical indication for the need of surgery.

If visual field tests are performed, the tests should show loss of 2/3 or greater of a visual field in the upper or temporal areas documented by computerized visual field studies, with visual field restored by taping or holding up the upper lid.

An UpToDate review on ptosis (Lee, 2013) states that “In patients with third nerve [oculomotor nerve] palsy, an interval of 6 to 12 months before surgical intervention is advised because many will have spontaneous recovery.  Similarly, patients with MG [myasthenia gravis] should have stable disabling ptosis for several months on maximal medical therapy before considering surgical therapy”.